Based on data from the Federation of State Medical Boards (FSMB) on the number of disciplinary actions taken against doctors in 2002-4, Public Citizen’s Health Research Group has calculated the rate of serious disciplinary actions (revocations, surrenders, suspensions and probation/restrictions) per 1,000 doctors in each state and compiled a national report ranking state boards by the rate of serious disciplinary actions per 1,000 doctors for the years 2002-4 (See Table 1).

In previous years, our ranking was based solely on the data from the most recent year. Because some small states do not have many physicians, an increase or decrease of one or two serious actions in a year can have a much greater effect on the rate of discipline in such states than it would in larger states. Therefore we are calculating the three-year average rate of discipline (for each year and the preceding two years) for all states and listing them by rank for each three-year interval so that trends in rank over the past decade can more accurately be examined (see Table 2). Again, the newest ranking is based on the three-year average rate, not the rate for 2004 alone.

Our calculation of rates of serious disciplinary actions (revocations, surrenders, suspensions and probations/restrictions) per 1,000 doctors by state is created by taking the number of such actions (the first two categories of the FSMB data) and dividing it by the American Medical Association data on nonfederal M.D.s as of December 2003[1](adding to this the number of osteopathic physicians[2] if the board is a combined medical/osteopathic board). We then multiplied the result by 1,000 to get state disciplinary rates per 1,000 physicians. This rate calculation is done for each of the last three years (2002-2004), and the average rate is used as the basis for this year’s state board rankings.

There were 3,296 serious disciplinary actions taken by state medical boards in 2004, up 10.1% from the 2,992 serious actions taken in 2003. The three-year state disciplinary rates ranged from 1.44 serious actions per 1,000 physicians (Hawaii) to 10.04 actions per 1,000 physicians (Wyoming), a 7-fold difference between the best and worst states.

Worst States (those with the lowest three-year rate of serious disciplinary actions).

Table 2 shows that five of these 15 states, (Wisconsin, Minnesota, Tennessee, Delaware, and Hawaii) have always been in the bottom 15 states for the last ten 3-year periods. In addition, six of these 15 states have been in the bottom 15 for at least five of the past three-year periods: South Carolina and Florida (5), Washington (6), and Maryland and Connecticut (8). Large decreases of at least a 20-state drop in ranking have occurred from the 1993-1995 ranking to the current rank in four states: Maryland went from 23rd to 47th; Mississippi, from 4th to 40th; Nevada, from 21st to 46th and South Carolina, from 20th to 43rd.

These data again raise serious questions about the extent to which patients in many of these states with poorer records of serious doctor discipline are being protected from physicians who might well be barred from practice in states with boards that are doing a better job of disciplining physicians. It is quite possible that patients are being injured or killed more often in states with poor doctor disciplinary records than in states with consistently high performance.

Best States (those with the highest rates of serious disciplines).

The top 10 states are (in order): Wyoming (10.04 serious actions per 1,000 physicians), Kentucky (9.32 actions per 1,000 physicians), North Dakota (7.65 per 1,000 physicians), Alaska (7.44 per 1,000 physicians), Oklahoma (6.95 per 1,000 physicians), Arizona (6.68 per 1,000 physicians), Ohio (6.64 per 1,000 physicians), Montana (6.40 per 1,000 physicians), Colorado (6.18 per 1,000 physicians) and West Virginia (5.33 per 1,000 physicians). All of these top 10 states were also in the top 10 in last year’s three-year ranking.

As can be seen in Table 2, three of these 10 states (Wyoming, Oklahoma and Alaska) have been in the top ten for all ten of the three-year average periods listed. Five other of these top 10 states have been in the top 10 for at least six of the last ten three-year periods: Colorado and Arizona (6), Kentucky (7) and Ohio and North Dakota (8).

It is clear that state-by-state performance is spotty. Only one of the nation's 15 largest states, Ohio, is represented among those 10 states with the highest disciplinary rates. Illinois and Pennsylvania, other large states, have usually been near the bottom although Illinois has improve more recently, ranking 25th. California and New Jersey have hovered around the middle. Massachusetts, consistently in the bottom 15 states for the three-year averages until the 2001 three-year average, has improved substantially since then, now ranking 23rd.

What Makes a Difference?

Boards are likely to be able to do a better job in disciplining physicians if most, if not all, of the following conditions are true:

Adequate funding (all money from license fees going to fund board activities instead of going into the state treasury for general purposes)

Adequate staffing

Proactive investigations rather than only following complaints

The use of all available/reliable data from other sources such as Medicare and Medicaid sanctions, hospital sanctions and malpractice payouts

Excellent leadership

Independence from state medical societies and other parts of the state government

A reasonable legal framework for disciplining doctors (preponderance of the evidence rather than beyond reasonable doubt or clear and convincing evidence as the legal standard for discipline).

Most states are not living up to their obligations to protect patients from doctors who are not practicing medicine in the best manner and are thus endangering the lives and health of residents. Serious attention must be given to finding out which of the above variables are deficient in each state. Then action must be taken, legislatively and through pressure on the medical boards, to increase the amount of discipline and, thus, the amount of patient protection.

[1] Physician Characteristics and Distribution in the U.S. American Medical Association, 2005 Edition.